The nurse observes the following rhythm of a client on the telemetry unit.
Which action should be completed first?
Report the findings and anticipate a medical prescription for amiodarone
Initiate a rapid response call and increase the monitor's sensitivity
Start compressions and prepare for defibrillation
Establish unresponsiveness and check the carotid pulse
The Correct Answer is D
A. Reporting the findings and anticipating a prescription for amiodarone may be necessary later, but the first step is to assess the patient's immediate condition (unresponsiveness, pulse status, etc.).
B. Although increasing monitor sensitivity and initiating a rapid response call might be helpful, these actions come after assessing the patient’s condition. If the patient is in distress or unresponsive, the nurse needs to check for a pulse and intervene right away.
C. This is a crucial action if the patient is unresponsive and pulseless (cardiac arrest). If the patient is found to be unresponsive and pulseless, starting chest compressions immediately and preparing for defibrillation is the next step. However, the first action is to check for pulse and responsiveness.
Why it's incorrect: Compressions and defibrillation are correct actions if the patient is pulseless, but before taking these steps, the nurse must assess the patient for responsiveness and check the carotid pulse. Starting CPR and preparing defibrillation without verifying the patient's condition could delay appropriate care.
D. Checking responsiveness and pulse is the most immediate and critical action because VT may be asymptomatic or cause deterioration, including cardiac arrest. Once pulse and responsiveness are determined, appropriate interventions (such as defibrillation or CPR) can be initiated quickly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. “I probably will not have any transfusion reactions from my own blood.” - Autologous transfusions
generally have a lower risk of transfusion reactions because they involve the client’s own blood.
B. “This is the blood I’ve been giving for the past 6 weeks for myself.” - This is a correct understanding of the process of autologous blood donation, where the client donates blood for their own use.
C. An autologous blood transfusion involves the collection and storage of a patient's own blood for later transfusion. This significantly reduces the risk of bloodborne infections, such as hepatitis, HIV, and other blood-borne diseases, as the blood is coming from the patient themselves.
D. “Since I have O negative blood, it’s a good thing I’m getting my own blood.” - The client may not need additional teaching here because O negative blood is universally compatible, but the reason they are getting their own blood is due to the autologous donation process, not because of blood type.
Correct Answer is ["13.8"]
Explanation
The patient weighs 121 lbs, which is approximately 55 kg (121 ÷ 2.2).
The prescribed dose is 1 mg/kg, so the patient requires 55 mg of furosemide. The medication is supplied at a concentration of 40 mg per 10 mL.
To find out how many mL of furosemide to administer, set up a proportion: 40 mg is to 10 mL as 55 mg is to X mL.
Therefore, the nurse should administer 13.8 mL of furosemide, rounding to the nearest tenth.
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